Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

I am very confused and extremely frustrated. I have been a
nurse and a Lamaze educator for many years and I have always kept
up with research. However, I just found out yesterday
that our hospital is doing elective inductions routinely at 39
weeks because the research says that there are no different
outcomes for mom and baby in comparison to spontaneous onset of
labor. I was referred to the Institute of Health care website
where I found a Clinician's Guide on this topic, but I failed to
read it and have this interpretation. PLEASE can you tell me
what ACOG guidelines are on elective inductions currently and can
you comment on the study they referred to entitled Maternal and
Neonatal Outcomes of Elective Induction of Labor: A Systematic
Review and Cost-Effectiveness Analysis (2008) by Stanford
University?

Let’s start
with guidelines. ACOG’s 2009 induction guidelines (citation
below--no electronic link available) make no mention of
induction’s effect on delivery route except to say that
cervical ripening reduces the rate of “failed
induction” (p. 386), that an unfavorable cervix is defined as
having a Bishop score less than 6 and that with scores > 8
“the probability of vaginal delivery after labor induction is
similar to that after spontaneous labor” (p. 387). This would
seem to imply that using cervical ripening agents with an
unfavorable cervix gets rid of the problem of “failed
inductions,” but this is not the case. I have just finished
reviewing the studies on elective and preventive induction, a.k.a.
AMOR-IPAT, a pseudo-scientific system for justifying elective
induction, for the upcoming new edition of Obstetric Myths Vs.
Research Realities, and I can tell you that ACOG’s
circumlocutions obscure that cervical ripening with an unripe
cervix does not eliminate the excess risk of c/sec, that studies
consistently show that women having a first baby have roughly
double the risk of c/sec when induced electively compared with
spontaneous labor onset, and that women with only prior vaginal
births also have an increased risk--although the excess cesarean
rate is much smaller--when induced with an unripe cervix, ripening
agent or not. As for indications, ACOG states, “Labor
also may be induced for logistic reasons, for example, risk of
rapid labor, distance from hospital, or psychosocial
indications” (p. 389), which pretty much covers the board for
inducing electively other than ob on vacation. They do add
that induction should not be attempted until the fetus has reached
“39 weeks of gestation” or lung maturity is documented,
but this is hardly reassuring. For one thing, I put that number in
quotation marks to show that it is ambiguous. The new mandate is
not to attempt elective delivery until 39 completed weeks,
or the beginning of the week that ends with the due date. For
another, the guidelines say that an ultrasound measurement as late
as 20 wks is sufficient to firmly establish gestational age, which
believe me, it isn’t with second trimester
ultrasounds.

The U.K. also has
induction
guidelines produced by the National Institute for Health and
Clinical Excellence and updated as of 2008. The contrast with
ACOG’s guidelines is striking, especially when one considers
that the U.K. has a much better reputation for basing maternity
care guidelines on the evidence and that their guidelines are
developed by an independent group of representatives of all
stakeholders, not a single professional organization interested in
protecting the interests of its members and without input from
others or external oversight. The NIHCE introduction states:
“When labour was induced [in the U.K.] using pharmacological
methods (whether or not surgical induction [breaking the bag of
waters] was also attempted), less than two thirds of women gave
birth without further intervention, with about 15% having
instrumental births and 22% having emergency [just means cesareans
during labor] caesarean sections. Induction of labour has a large
impact on the health of women and their babies and so needs to be
clearly clinically justified” p.3. Presumably for this
reason, the section on indications for induction states:
“Induction of labour should not routinely be offered on
maternal request alone. However, under exceptional circumstances
(for example, if the woman’s partner is soon to be posted
abroad with the armed forces), induction may be considered at or
after 40 weeks” (emphasis mine) (p.12).

Turning to the
government-sponsored systematic review to which the doctors at your
hospital referred, I have both the full
Agency for Healthcare Research Quality review and the summary
paper published in the Annals of Internal Medicine. The short
version is that if you are familiar with the AHRQ systematic review
of so-called “maternal request cesarean,” this is more
of the same: a heavily flawed review conducted by strongly biased
reviewers--in the case of elective cesarean, led by a
urogynecologist and in the case of elective induction, by a
co-author of papers advocating “preventive induction,”
which, as I mentioned above, is elective induction by another
name.

Time and space
prevent enumerating all the problems with this review, but let me
hit a few highlights, starting with theory. The reviewers argue
that the large body of research comparing elective induction with
spontaneous labor week-by-week after term, which consistently finds
that inducing increases risk of cesarean even after adjustment for
factors such as birth weight, is not valid. The real question is
not the comparison in any given week, but whether women reaching
term are better off with planned induction at some given point
given that planned expectant management will end in substantial
numbers of women being induced later on and having even greater
rates of c/sec as a result and that the rate of c/sec rises as
gestational age increases even with spontaneous onset. The flaw in
that argument is the assumption that high induction rates and
higher c/sec rates as gestational age advances are inevitable
rather than a matter of practice variation. Studies in which
physiologic care was the norm firmly come down on the side of the
latter. Among 5 studies of planned home birth and a sixth study of
a rural hospital with no c/sec capability (Ackerman-Liebrich
1996; Janssen
2002; Johnson
2005; Leeman
2002; van
der Hulst 2004; Woodcock
1994), induction rates overall ranged from 2% to 14% and total
c/sec rates from 4% to 8% with equally good outcomes compared with
similar women planning hospital birth.

The reviewers then
turn to randomized controlled trials of elective induction to make
their case. The reviewers call the comparison group
“expectant management,” but I will call it the
“control group” because elective induction was
explicitly permitted in two of the trials, including Hannah (1992),
by far the largest. The RCTs, in contrast to the observational
studies, consistently find increased c/sec rates in the control
group arms of the trial. Furthermore, more babies in the control
group had meconium stained amniotic fluid. Starting with meconium
staining, babies may have been more likely to have staining, but
they did not have more meconium aspiration, which is the real
concern. Meconium staining in the absence of other symptoms merely
represents normal variability in maturing intestinal tracts. As for
excess cesareans in the control group, let’s take a closer
look. The Hannah 1992 “postterm” trial, actually an
elective induction trial because women in the induction arm were
induced after reaching 41 wks, not 42, is by far the largest of the
elective induction trials, making up more than half of all
participants in the analyses of pooled data from the RCTs. It
epitomizes the problems found in all the RCTs. I won’t go
into them here because
I have critiqued this trial elsewhere on the Lamaze website,
and that critique illustrates flaws that affect all of
them.

These flaws, I
should point out, will be invisible to people with the medical
model perspective that a pregnant or laboring woman is X marks the
spot where something can go wrong at any moment and that the care
provider’s role is, whenever possible, to rescue the baby
before disaster can occur. Clinicians with this viewpoint will find
nothing peculiar with the Hannah trial, to cite a glaring example,
reporting cesarean surgery rates more than 20% in both arms of the
trial despite all participants being healthy women with intact
membranes and no prior cesareans (if they had previous children),
carrying healthy, full-term, singleton, head-down babies. The staff
at your hospital undoubtedly fall in this category. I wish you luck
with trying to convince them otherwise, but I'm pessimistic about
your chances.

-- Henci

ACOG. Induction of labor. ACOG Practice Bulletin No 107,
2009.

All Times America/New_York

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